MILWAUKEE HEALTH SERVICES, INC.

Milwaukee Health Services, Inc. (the "Organization") submits the following corrective action plan for the identified finding and questioned costs for the year ending January 31, 2025. Finding 2025-001: Special Tests and Provisions - Sliding Fees Statement of Condition: External auditors reviewed 40 sliding fee transactions to verify if the amount charged under the Organization's sliding fee program was calculated properly based on the patient's income level and in compliance with the Organization's sliding fee policy. External auditors noted that two ofthe sampled transactions were not properly determined resulting in the patients being over or undercharged for services. Corrective Action: The Organization will review its sliding fee policies and monitor determinations. Staff responsible for sliding fee determinations will be trained on properly computing sliding fees. The Organization will also review the system controls and safeguards within OCHIN Epic (Electronic Health Record) for assisting in sliding fee calculation accuracy. Person Responsible for Corrective Action: Joyce Nwatuobi, Chief Financial Officer Anticipated Timing for Completion of Corrective Action: November 30, 2025.

Milwaukee Health Services, Inc. ("MHSI") submits the following corrective action plan for all identified findings and questioned costs for the year ending January 31, 2023. Finding 2023-002: Sliding Fee: External auditors reviewed 40 sliding fee charges to test if the amount charged, was calculated properly based on the patients’ income level and in compliance with Milwaukee Health Services’ sliding fee policy. External auditors noted that 2 of the charges were not properly determined or information was not retained to determine if the charge was properly determined. Corrective Action: HRSA performed a site visit regarding the 330 Grant in May 2023. During that site visit, the Sliding Fee Discount program requirement was classified as “met”. The audited timeframe for this fiscal year was during the period when we transitioned, on June 21, 2023, from the Centricity Electronic Health Record (EHR) to the OCHIN Epic EHR. Of the 40 Sliding Fee charges tested, there were 2 failures. Both failures were from charges selected in the Centricity EHR. No fails were identified in the OCHIN Epic EHR, which has built in safeguards to assist in Sliding Fee calculation accuracy. Responsible current staff have been re-trained, and new staff are being trained as part of the on-boarding process. 100% of Sliding Fee accounts will be audited from February 1, 2023, and forward. Any required corrections will be made immediately. Any impacted accounts will be appropriately reprocessed when identified. All forms related to Sliding Fee determination will be scanned into the OCHIN Epic system and will be reviewed for quantity and quality, prior to disposing of any paper copies. Person Responsible for Corrective Action: Chief Financial Officer (Laurie Yake), Revenue Cycle Director (Leeann Stoiber) Anticipated Timing for Completion of Corrective Action: November 30, 2023.

Milwaukee Health Services, Inc. ("MHSI") submits the following corrective action plan for all identified findings and questioned costs for the year ending January 31, 2020. Ok Finding 2020-001: Sliding Fee Statement of Condition: WIPFLI reviewed 43 sliding fee charges to test if the amount charged, was calculated properly based on the patients' income level and in compliance with Milwaukee Health Services' sliding fee policy. Corrective Action: HRSA performed a site visit regarding the 330 Grant in May 2019. During that site visit, the Sliding Fee Discount program requirement was classified as "met". The audited timeframe for this fiscal year was during the period when we were rewriting policy language, updating procedures and training new staff. The automated Sliding Fee calculator in the Centricity system is being utilized. Responsible current staff have been trained, and new staff are being trained as part of the on-boarding process. 100% of Sliding Fee accounts are being audited and corrections are being made immediately in the Centricity system and on related forms. The Billing Department is being notified of corrections, and bills are appropriately being reprocessed . Additional staff are being recruited to ensure that all aspects of the sliding fee process are reviewed and working properly. Identified problems in the system will be highlighted for immediate corrective action. A Sliding Fee task force will meet on a monthly basis to review audited results and address any resulting issues. Person Responsible for Corrective Action: Chief Financial Officer (Laurie Yake), Chief Operating Officer (Michele Grant) Anticipated Timing for Completion of Corrective Action: November 1, 2020. Respectfully submitted, Laurie B. Yake, Chief Financial Officer

2019-001

Milwaukee Health Services, Inc. ("MHSI") submits the following corrective action plan for all identified findings and questioned costs for the year ending January 31, 2019. Finding 2019-001: Sliding Fee Statement of Condition: Wipfli reviewed 40 sliding fee charges to test if the amount charged, was calculated properly based on the patients' income level and in compliance with Milwaukee Health Services' sliding fee policy. Wipfli noted that 5 of the charges were not properly determined and 3 charges were not supported. Corrective Action: Health Resources and Services Administration (HRSA) performed a site visit regarding the 330 grant in 2016. During the site visit, the sliding fee discount program requirement was classified as "not met". The Sliding Fee Discount policy revisions were subsequently taken to the Board of Directors for more than one update in an effort to have the program requirement "met". MHSl's leadership worked with the HRSA Fiscal agents along with their project officer to ensure the policy was worded properly and the intention of the program was met. Following HRSA lifting the condition for this program requirement, MHSI recreated the registration forms and the sliding fee discount document to match the new board approved policy language. Leadership also performed training for all staff on the updated policies and procedures. We provided continuous training with responsible staff to ensure the Sliding Fee Discount program would apply consistently for all patients as appropriate. HRSA performed a site visit regarding the 330 Grant in May 2019. During that site visit, the Sliding Fee Discount program requirement was classified as "met". The audited timeframe for this fiscal year was during the period when we were rewriting policy language, updating procedures and training new staff. The Sliding Fee Policy was updated in May 2019 to require only one pay stub to be submitted. The automated Sliding Fee calculation in the Centricity system is being utilized. 100% of Sliding Fee accounts are being audited and corrections are being made immediately in the Centricity system and on related forms. The Billing Department is being notified of corrections, and bills are appropriately being reprocessed. Person Responsible for Corrective Action: Chief Financial Officer (Laurie Yake), Chief Operating Officer (Michele Grant) Anticipated Timing for Completion of Corrective Action: August 8, 2019.

2018-001

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